Friday, September 30, 2011

Here is another in my occasional series about new food products offered by entrepreneurs here in Boston or elsewhere. I encountered Diane from the Smiling Sauce Company, where she was displaying her wares and offering samples at the Copley Square farmer's market.

The neat thing about these sauces is their temporal nature. Each variety is only available for two or three months, based on the availability of fresh local ingredients. They are meant to be refrigerated.

I tried a few flavors in Copley Square, with my favorite being Kick!, described as "a whimsical and healthy ketchup." Avoiding high fructose corn syrup, it is sweetened with honey. I bought three, knowing one wouldn't last long enough. I was thinking of giving the last to a friend, but am reconsidering, as maybe two won't be enough either.

Tuesday, September 27, 2011

Narcissus was so entranced by a reflection of his own image that he was paralyzed into inaction by looking at it, leading to an unfortunate end. There is a lesson here for the country's academic medical centers (AMCs). These "crown jewels of American medicine" are lobbying to be exempt from certain federal budget cuts. As noted in a paid op-ed page advertisement in the New York Times,* they cite their special status as "urban medical centers treat[ing] patient populations with high rates of chronic disease, coexisting conditions, and more advanced stages of illness." They note that "physicians and scientists at teaching institutions are the foundation of biomedical research and innovation in medicine [where] they invent and improve surgical devices and . . . inform drug discovery and development." Finally, they remind us of their essential role in training the next generation of physicians.

All this, being true, is viewed by the ad's author and many of his peers as sufficient reason to inoculate the AMCs from possible cuts in graduate medical education (GME), the portion of the Medicare budget that funds residency training programs. But these statements fail to tell the story of how academic medicine, in many institutions, is failing the American public.

It does not, for example, explain why many AMCs have been slow to adopt proven tools of process improvement to reduce harm to patients and improve efficiency. Indeed, some "trophy" faculty members who are widely published in these arenas and assist such implementation in community hospitals have been known to be systematically ignored by their home institutions. Meanwhile, those who learn and do this work are saving hundreds of lives and millions of dollars.

It does not explain the persistent lack of transparency in many such institutions with regard to clinical outcomes, notwithstanding the documented value of such transparency in improving quality and safety. As noted by President Paul Wiles at Novant, "With our results in the public domain we have a real incentive to make our results better."

It does not explain why the medical schools that own or are affiliated with many AMCs have failed to train their students in how to use the scientific method to improve the delivery of care. As the Lucien Leape Institute notes: [M]edical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer.

It does not explain the huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine. Brent James describes this as, "well-documented massive variation in practice based on local medical myths." He notes:

We continue to rely on the "craft of medicine," in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.)

Compare this to the approach taken at the Mayo Clinic, where "the most important thing we can teach our residents and trainees is the value of standard work."

It does not explain the reluctance of many AMCs to engage patients and families in the design and delivery of care. Instead, customers might be treated as empty vessels, into which clinical decisions about testing and therapies are poured. The contrast with how things might work, as exemplified here, is stunning.

Raise these issues with people at many AMCs, and they, briefly looking away from their reflection, say, "You don't appreciate what we do."

Ah, we do appreciate it. We just think you can better.

It's time for the many slower moving AMCs to demonstrate your commitment to an improvement in the delivery of patient care. Make that part of your mission. Ensure that it is as scientifically valid and academically important to your faculty as new devices, drugs, diagnostic tests, and basic science journal articles. Show us that you can help integrate the care of your patients with primary care doctors, skilled nursing facilities, and rehabilitation centers as well as you run your transplant services, ICUs, and trauma centers. Demonstrate true patient and family involvement in the diagnostic and treatment decisions in you hospital.

Show us that this is all part of your GME program, and we'll be happy to keep paying the freight. Absent that, you are training doctors for the wrong future.

---

* "Urban Teaching Hospitals Disproportionately Targeted for Medicare Cuts," Kenneth L Davis, President and CEO of The Mount Sinai Medical Center in New York City. September 27, 2011.

The Pennsylvania Health Care Cost Containment Council ("PHC4") has posted its latest annual report entitled, "Good Data Drives Good Decisions." [Undated, but marked as "new" on the website, as seen above.] It is so thoughtfully and clearly written that I would like to say, "Well done," but no, it is not.

From the introduction:

Now more than ever, PHC4’s data on the cost and quality of health care services is needed to make informed decisions, to facilitate competition in the health care arena, and to critically evaluate the value Pennsylvanians receive in return for their health care dollars. In the coming years, good data will be needed to thoughtfully implement health care programs and to evaluate their effectiveness. Good data is also essential in identifying and eliminating significant cost drivers, such as preventable waste and error. The Council can serve as a valuable resource in providing this data.

The problem, as I noted in the past with regard to Massachusetts data and Federally provided data, is timeliness. Although the report is dated 2010, the numbers presented are much older. The report discusses chronic health conditions and payments for them in 2007; hospital-specific information for 31 common procedures and treatments performed in Pennsylvania’s general acute care hospitals from October 1, 2008 to September 30, 2009; coronary artery bypass graft (CABG) and/or valve surgeries performed in Pennsylvania in 2007 and 2008; readmissions in 2008; hospital acquired infection data from 2009; financial results from FY 2009.

Not mentioned in the annual report, but available elsewhere on the website, are more recent financial reports, for FY2010. Now we are getting better, but even those were not published until September 2011.

As I said with regard to Massachusetts, "Don't you think we deserve more timely information about the quality of our [care] than we can get about cars, airplanes, and commuter rail?"

And, "We all appreciate the steps the state is taking, but if we are going to be serious about transparency, let's improve what is posted so consumers have up-to-date and accurate information."

And, "While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror."

"[The government] information reported needs to be a lot more up to date, said Carolyn Clancy, director of the Agency for Healthcare Research and Quality. "We're not so good at timely transparency," she said. "We must get to a place where we get data in something like real time."

Some will say that I am being too picky, but I just don't see how these PHC4 data or other such data from other states help "to make informed decisions, to facilitate competition in the health care arena, and to critically evaluate the value Pennsylvanians receive in return for their health care dollars."

Maybe some people from the state, including those members of the PHC4 board, will dispute this and give us all a better explanation. Here's the list and a promise to print anything they post on this blog in reply:

Sunday, September 25, 2011

Following on a successful event last year, Neel Shah and his colleagues at Costs of Care have announced their 2011 Essay Contest. Their goal is to expand the national discourse on the role of providers in health care spending. Neel notes:

This year our judges will include former White House Budget Director Peter Orzsag, former surgeon general C. Everett Koop, former Michigan Governor Jennifer Granholm, women's health advocate Dr. Susan Love, and incoming Harvard University provost and health economist Dr. Alan Garber. We'll be offering $4000 in prizes for top submissions. In addition to stories about price transparency and unexpected medical bills, this year we are also particularly looking for positive stories that illustrate ways to save money while still delivering high value care.

Costs of Care is a nonprofit social venture that helps doctors understand how the decisions they make impact what patients pay for care. They aim to harness social media, mobile applications, and other information technologies to give doctors and patients the information they need to deflate medical bills.

For this contest, two $1000 prizes will be reserved for patients, and two $1000 prizes will be reserved for care providers. Preference will be given to stories that best demonstrate the importance of cost-awareness in medicine. Examples may include a time a patient tried to find out what a test or treatment would cost but was unable to do so, a time that caring for a patient generated an unexpectedly a high medical bill, or a time a patient and care provider figured out a way to save money while still delivering high-value care.

Saturday, September 24, 2011

To highlight some of the critical work being done at the Goodman Cancer Research Centre, we gathered some of our top scientists, students, lab techs and dedicated volunteers, who turned on the music - and danced!

Friday, September 23, 2011

I have made previous mention of the Boston Courant, one of the last standing local newspapers in town. They celebrate today their 16th anniversary. To prove their place of permanence in the journalistic hierarchy, note this bit of graffiti on the Pesky Pole in Fenway Park.

One of my regular readers threw down the gauntlet after a recent post:

Hi Paul. You are very discerning about the problems we face. This last blog of yours is a criticism of what the President has said. You have also, rightly in my view, urged caution regarding global payments.

What I would appreciate from you is your suggestions for dealing with the rising costs of health care.

Howard

First, we have to acknowledge that a large portion of the rise in health care spending in the developing countries is caused by demographic trends. The elderly are living longer and the baby boomers are reaching the age that requires tertiary care. Both groups, too, are incredibly entitled and want interventions that in previous eras would have been unavailable; e.g., knee and hip replacements. Looking ahead to the next generation, we see an epidemic of obesity accompanied by its friend diabetes, with high cost sequelae like kidney disease, heart disease, vascular disease, and eye deterioration.

Second, we have created a medical arms race that feeds on and into these trends. Whether robotic surgery, proton beam emitters, or smaller devices, manufacturers and investment bankers have learned how to create markets for such inventions that take hold well in advance of evidence of clinical efficacy or cost-effectiveness. Ditto for direct-to-consumer approaches to pharmaceuticals.

Third, we have a regulatory and accreditation system in place for hospitals that focuses on bureaucratic and often picayune "conditions for participation" or "requirements for improvement" that do not address systemic flaws in the way work is done in hospitals.

Fourth, there is virtually nothing in the medical education process that teaches young physicians and nurses about the science of process improvement. Likewise, the educational process virtually ignores the potential value that patients and families have in creating clinical partnerships that result in less harm and greater efficacy.

Fifth, there is an appalling lack of transparency in our health care system with regard to clinical outcomes. Such data as are published are stale. Ditto for cost and price data that might influence both providers and consumers in their choice of diagnostic tools, therapies, and location of care.

Finally, health care is such a large part of our economy that political approaches to these problems inevitably hit the wall of special interests who stand to lose by changes. The expression, "one person's costs is another person's income," provides a shorthand for the cause of political and administrative gridlock on these items.

One could easily conclude from this list that all is hopeless, that the only way to bend the cost curve is to impose administrative fiats that curtail the amount of money available to the providers in the health care system. Indeed, commenters on this blog have made such a point. Sure, it might cause some hardship and rationing, they argue, but at least we will start reducing the rate of increase.

This is the same argument used by tax limitation advocates in the past: Starve the beast, and the bureaucrats and politicians will finally be held in check. By definition, this is true, but it can have major unintended consequences. Proposition 13 in California and Proposition 2-1/2 in Massachusetts both succeeded in limiting taxes in their respective states, but both began a long downward cycle in the quality of public education and other governmental services.

So, Howard, where do we go from here? First, let's acknowledge that the solution is a long-tailed one. It will not take place during the period viewed as important by politicians, i.e., the next election cycle. Neither will it be resolved during the period viewed as important by businesses, i.e., the next financial report. It will take years, maybe decades.

In Jönköping County in Sweden, arguably the world's exemplar in such matters, the learning process took decades -- and with a political and social environment much less combative than ours.

In my former hospital, where we had an explicit strategy to be a low cost, high-quality, patient-centered environment, the cultural transformation involved took at least five years. Even then, we felt we were just getting starting in reaching aggressive clinical goals and eliminating waste in our processes. I am sure that other industry leaders, like those at Virgina Mason, Gunderson Lutheran, and Ascension, would say the same.

But, every journey must start with single steps, and we need to get to work. Each of the causes outlined above suggests its own remedy. The variety of causes also suggests that a single, global solution is unlikely to work. Anyone who says, "All we need is x (e.g., where x is global payments) is barking up the wrong tree. Incremental change along each front is called for, along with mid-course corrections when that change has unintended consequences.

All this only happens with a demonstration of clinical and administrative leadership from those in the field, and from the Boards of Trustees who oversee our institutions. Too many hospital CEOs, chiefs, and board members think they have "arrived" when they reach their high posts -- and then coast thereafter enjoying the salaries and/or prestige of their positions. Instead, they have to understand that they are facing the challenge of their lives -- fixing an unsustainable health care delivery system -- and progress will only occur when they move past their comfort range and have the intellectual modesty to learn from their patients and from those in other fields that have been through structural change.

In this blog, I have offered success stories in many of the problem areas mentioned above. I have also offered detailed policy prescriptions where government intervention could directionally make a difference. As in all other aspects of American life, though, broad and sustained progress will only occur when committed people let their views be known. It would help if a "barely restrained mob" of patient advocates could find its way to focus on key variables and demand accountability locally and nationally. But short of that mob, every citizen has right to let his or her voice be heard in their community. There is no magic bullet that can take the place of that. As Margaret Mead said,

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.”

Thursday, September 22, 2011

There are some symphonic masterpieces you can recognize by the opening triad. Likewise, when I happened to turn on my radio last night, I heard three words and said, "Oh, that's Steve Breyer." He was on Tom Ashbrook's On Point show on our local public radio station.

I first met Steve in 1974, when he was appointed to a Governor's study commission of which I was the staff director. He was then at Harvard Law School. The wisdom and brain power were evident even then.

Justice Stephen Breyer in the On Point studio. (Jesse Costa/WBUR)

But listen to this interview, in which Breyer talks about his new book, Making Our Democracy Work: A Judge’s View. Whether you agree with his legal decisions or not, you have to admit that this is the kind of person we want on our Supreme Court. Here's the link. Excerpts:

Ashbrook: Why did you write this [book]? What are you worried about?

Breyer: There’s a great deal of cynicism about our government and the younger the people, the more cynical they are. A little cynicism may be justified. But if there’s too much, the government won’t work. Because the Constitution itself depends on people participating, in good faith, in governmental processes: in elections, in their local communities, on their school boards, on library commissions. They have to have a public part. I think the best thing that people in public life, and a lots of us think this, can do, is explain to people the best we can, how our institutions work.

Ashbrook: There have been [court] decisions that many Americans have found very challenging. [In the year] 2000, of course, we saw the decision of the Bush-Gore elections in the Supreme Court. Highly controversial. Much more recently and under this president, we saw Citizens United, where the court said that corporations, unions, had the same rights as citizens to free speech.

Now, we’re headed into an election season for the president of the United States. This is a big deal. And this is going to be a time when that ruling is in place and the money is already rolling. And a lot of people are really upset about it. The people you are counting on to support the legitimacy, the clout, the power of the Supreme Court. What do you say to them when they look at Citizens United, which seems to so empower people who may be seen as citizens, but they are not human beings?

Breyer: I say three things: First, remember, we, in a sense, on the court patrol the boundaries. The Constitutions sets very broad boundaries. Life on the frontier, on those boundaries, is not always pleasant…Is abortion inside or outside the constitution? What about school prayer? What about Bush versus Gore? What about the cases you’ve mentioned? They are always pretty difficult cases and there something to be said on both sides.

I’d like people to remember that even when they disagree– and I disagreed in the cases you mentioned, I was in the dissent. I disagreed very strongly. But even in those cases where the Supreme Court has done something unpopular and where it might be wrong after all, we’re human. We are human beings. I mean people don’t always understand that, it’s certainly true. And if you’re a human being, you can make mistakes.

And therefore the job that I have right now is even tougher than you’ve suggested. Because I’m trying to say to the average man and woman in America, please read a little of this or learn a little of it, and you’ll see perhaps why this institution can help you. Even though you will disagree with it. And you may be right. And you may be wrong.

An important and positive attribute of the Affordable Care Act was the provision allowing young adults to stay on their parents' health insurance policies until age 24. Many of us faced this problem when our children finished college but were not yet established in employer-based insurance plans. An article by Kevin Sack in the New York Times summarizes the effect of this and contains the chart shown to the left.

Kathleen Sebelius, the secretary of health and human services, understandably and rightfully claimed victory on this point.

But embedded in the article is one of those quiet give-aways that remind us that the laws of economics hold. It reminds me of the old joke: "Gravity. It's not just a good idea. It's the law."

The point made was that this provision, alone, accounted for an increase in insurance premiums. "Mark F. Olson, a senior actuary with Towers Watson, the human resources consulting firm . . . and several insurance industry spokesmen credited it for raising enrollments and premiums by between 1 percent and 3 percent at many firms."

In another article, we learn that Hewitt Associates puts the average premium hike nationally at 8.8 percent, a result of several factors in addition to the health bill. So, something like 1/8 to 1/3 of the average premium increase might be due to this provision of the law.

Is that a lot or a little? I personally think it is worth it and good policy. But whatever the amount, it belies the claim made by the President during the health care debate that we could have access, choice, and lower costs. Indeed, when the law's provisions concerning guaranteed issue (e.g., eliminating exclusions for pre-exisiting conditions) come into effect in future years, there will be yet another bump up in rates to cover those people.

Wednesday, September 21, 2011

We have talked a bit on this blog about using financial incentives to encourage doctors to do a better, more efficient, and/or safer job in practicing medicine. I have been skeptical of this approach because I do not believe that doctors find such measures to be highly motivational. In my former hospital, we stayed away from financial incentives and even discussion of finances when we were instituting changes in work practices that improved quality and safety and the work environment. Instead, issues were framed in terms of the underlying values of doctors.

I understand, though, why the government and insurers tend to lean towards financial incentives. Payers, after all, deal in money. Thus, they think they can use money to achieve their goals. When you have a hammer, everything looks like a nail.

The payers have been persuasive with legislators and the senior executives at both the federal and state level, notwithstanding insufficient data to support their policy prescriptions. Later, as evidence emerges, the programs are proven not to work as expected. The latest such analysis of which I am aware is a Perspectives piece by Gail Wilensky in the New England Journal of Medicine entitled, "Lessons from the Physician Group Practice Demonstration — A Sobering Reflection." Here's the lede:

In early August, the Center for Medicare and Medicaid Services (CMS) announced the results of the Physician Group Practice (PGP) Demonstration project. Although the headline of the press release was glowing — “Physician Group Practice Demonstration Succeeds in Improving Quality and Reducing Costs” — the reported information suggests more mixed results. These results should dampen unreasonable expectations, particularly in terms of potential savings, for accountable care organizations (ACOs), which were modeled after the PGP demo.

I covered a different aspect of this topic in my recent article, "Never Events? Well, Hardly Ever," in Virtual Mentor. I discuss the persistent rate of wrong-site surgeries and argue that financial penalties for such "never events" are ineffective:

In the face of slow progress, there is little doubt why the regulatory hammer is employed. But it is a crude tool. Its effectiveness as a deterrent is minimal because it does not address the structural issues underlying the problem. It emphasizes a particular outcome rather than a process that will achieve it. It penalizes people when it is too late to make a difference. Finally, it serves mainly to create resentment among those who are targets for improvement. Such is often the nature of regulation, no matter how well intended.

Ori and Rom Brafman take us a down a different path to explain this kind of result in their book, Sway, The Irresistible Pull of Irrational Behavior (Broadway Books, 2008.) They cite experiments and real-life situations in which "throwing money into the mix diminished altruistic motivation and introduced unexpected behavior." Apparently, our brains have two centers that influence behavior. The posterior superior temporal sulcus, what they call the "altruism center," is responsible for social interactions -- how we perceive others, how we relate, and how we form bonds. The other region is the nucleus accumbens, or "pleasure center," where we react to financial compensation. Now here's the neat part:

Unlike, say, the parts of our brain that control movement and speech, the pleasure center and the altruism center cannot both function at the same time: either one or the other is in control.

Doctors are the most well-intentioned people in the world. They devote their lives to alleviating human suffering caused by disease. We can count on their altruism in the patient care arena. Admittedly, they are not always sufficiently trained in the science of process improvement, but a number of hospitals in the world have figured out that progress in that discipline comes from treating doctors with respect. Framing the theories of process improvement by relating them to the underlying values and altruism of doctors is the way to go. Throwing financial incentives into the mix, as noted by the Brafman's, may be the quickest possible way to turn off the altruism switch and end up with unintended consequences.

Medication safety has gotten a lot more challenging in the past year or so, due to circumstances health care providers can’t typically predict or control: a growing, critical shortage of prescription drugs, hundreds of them, including mainstay generics hospitals use to treat several forms of cancer. News organizations have begun to pay attention to the trend because of the tough decisions providers and patients now face when preferred treatments for certain types of aggressive leukemia or testicular cancer aren’t available. A recent story on The PBS NewsHour offers one of the more comprehensive looks at the underlying industry practices, product decisions, and manufacturing problems that have led to the crisis—a crisis that’s enabled a gray market to now traffic in scarce supplies of certain drugs in order to offer them for sale at astronomically higher prices.

Against this backdrop, and while policy makers, members of Congress, and the US Food and Drug Administration seek both short-term and longer-term solutions, hospitals have no choice but to develop strategies and best practices that assume, for now, prescription drug shortages. WIHI is pleased to welcome three people to the September 22 program who have their fingers on the pulse of what’s going on and are actively working to help organizations effectively manage a complex situation. IHI’s Frank Federico, the ISMP’s Michael Cohen, and WakeMed’s Lynn Eschenbacher are three pharmacy-trained improvers who’ve tapped their expertise on medication safety to come up with new strategies that can enable hospital staff to stay on top of the fast-moving drug shortage problem on a daily basis. WIHI host Madge Kaplan can’t think of a better moment to benefit from their knowledge and to learn how Lynn Eschenbacher’s hospital system in particular is effectively dealing with the crisis.

In addition to viewing the PBS broadcast, in preparation for the Sept 22 WIHI we invite you to read a new article in Healthcare Executive about the drug shortages, written by Frank Federico, Bona Benjamin, and Michael Cohen. We’d also like to draw your attention to a Premier healthcare alliance analysis of the gray market, which provides critical facts and guidance for hospital pharmacists and staff who purchase prescriptions.

We look forward to your participation on this next WIHI, and we hope you’ll encourage any of your colleagues who are trying to better understand and manage the drug shortage situation to join us as well. Thanks!To enroll, please click here.

The UPMC kidney transplant story of a person infected by a diseased organ, about which I wrote in July, entered a predictable chapter yesterday with the filing of malpractice lawsuits. I imagine some will say, "You see, this is why they should not be transparent about the underlying systemic causes of the error." I would say, "Not so. Without sufficient transparency about the causes, and by simply blaming two clinicians, the chance of something else going wrong in the future is elevated. The lawsuit will rise or fall on its own merits. It is better to derive something good from the learning opportunity presented by the incident. But that can only happen when it is openly discussed and evaluated in a wider forum. Also, you have a moral obligation to inform other transplant centers about the string of events that led to this conclusion."

Tuesday, September 20, 2011

A friend offered a comparison between Manchester United fans mocking Chelsea rival Fernando Torres after he missed an easy goal and figures in Boticelli's Divine Comedy. He says, "Too bad Botticelli is not around to render this on canvas."

I say he would have missed it anyway, since he'd be watching the Serie A games instead.

I had my annual physical yesterday, and my doctor and I were discussing whether it is worthwhile to have a PSA test. (My previous test results, as late as last year, were very low.) As I understand things, the test is not proven to be determinative of anything. So, even if the value goes up dramatically, it is not necessarily a sign of cancer. It might, for example, be a noncancerous condition like BPH. The test can also produce false negatives, i.e., an indication that all is well when cancer is in fact present.

[Richard J.] Ablin has been frustrated by the widespread use of the test. Each year, he notes, some 30 million men undergo PSA testing, at a cost of $30 Billion. Yet “the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “

He acknowledges that “Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”

"The American Cancer Society recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information."

So, there we have it. Should I cause scarce health care dollars to be spent on a test that will not give me useful information? Or, to put it another way, why go through the potential stress of a higher number if it is not necessarily indicative of a problem? Or should I cause these dollars to be spent so, if the number remains low, I have a false sense of security?

I was pleased to be invited back last night to talk with Joe Restuccia's class at Boston University. The class is part of the MBA program and is entitled: "Health Services Delivery: Strategies, Solutions, and Execution."

Here is the course description:

With the increasing demand placed upon health care organizations to provide effective and efficient health care services, management of these organizations requires

a high level of knowledge and skill. This course is intended to provide knowledge and skills needed to design and operate systems capable of delivering accessible, high quality, efficient health care services. In particular, it will emphasize organizational transformation in order to achieve high performance, drawing upon relevant information from discipline-based and application areas of study including strategy, operations, marketing, finance, law, human resources, organization behavior, quality improvement, and information technology.

Joe is Professor of Health Care and Operations Management and Dean’s Research Fellow in the BU School of Management’s Department of Operations and Technology Management. He also holds the positions of Research Scientist at the VA’s Center for Organization, Leadership and Management Research and of Visiting Professor at Bocconi University School of Management in Milan, Italy. He is the perfect instructor for this kind of course, as his 35 years of research have focused on issues related to health care quality measurement and improvement, cost containment, information technology, and evaluation of interventions intended to improve effectiveness of health care delivery.

He lists the objectives of the course as to build students' ability to:

Recognize and evaluate the problems that exist in health care delivery organizations and systems

Apply knowledge and skills derived from various management disciplines to analyze and improve health care organizations and delivery systems

Organize and support your understanding through qualitative and quantitative analysis

My role was to tell the story of the cultural transformation at my former hospital, stressing the impact of transparency on the process improvements we achieved over several years. The students were active and thoughtful participants in the discussion, and I promised that I would include pictures of those who gave the best answers here. I do so with their names included so potential employers out there will know who they are when they apply for jobs!

Monday, September 19, 2011

I am very pleased to help announce and strongly encourage you to attend the Northeast Shingo Prize Conference on October 5-6 in Springfield, MA. The theme, "Made Lean in America," sets forth the premise of the conference, that greater competitiveness and efficiency is possible in many sectors of our economy by adopting the principles of Lean process improvement.

The conference is organized by GBMP (Greater Boston Manufacturing Partnership), a not-for-profit group whose mission is to sustain a strong and vibrant regional economy by improving the operational profitability and competitiveness of existing and emerging organizations, large and small, through training in Lean and continuous improvement principles. GBMP was of substantial help to me and my hospital as we introduced Lean to our leadership and staff. I do not exaggerate when I say that their advice saved us millions of dollars, improved the work environment, and enhanced patient care in our hospital.

Starting with an introductory address by John Shook, CEO of the Lean Enterprise Institute, entitled, "Outsourcing: The Big Lie," the sessions move on to a compendium of practical advice, progress reports from a variety of industries, and ample opportunities for networking. It will be excellent for health care people, but also those from other fields. You can register for the conference here.

GBMP's President, Bruce Hamilton, is probably best known for his video Toast, an introduction to Lean concepts. Here he is with an abbreviated version about the conference (click here if you cannot see the video):

Sunday, September 18, 2011

Steward Health System has announced a health insurance program designed to be 15 to 30 percent less expensive than comparable plans in the market. Steward is the for-profit owner of what used to be the Caritas Christi hospital system and some other hospitals in Massachusetts. This is a limited network product, requiring that care be given at one of the Steward hospitals.

Of note is this exception: Patients requiring specialized care will be referred to Massachusetts General Hospital or Brigham & Women’s Hospital in Boston, the flagship hospitals of Partners Healthcare System.

That last part suggests two options, in that MGH and BWH are not close to being the low costs providers of tertiary care in the Boston metropolitan market.

Option #1 -- Steward has decided that the marquee value of these two hospitals is worth the differential in payments compared to their competitors. That such a reputational advantage might persist in the marketplace is the direct result of a lack of transparency with regard to clinical outcomes. That is, the public has no way of knowing whether the results achieved at these two hospitals are any better or worse than the other tertiary centers.

Option #2 -- MGH and BWH have decided to discount their rates substantially from those charged to other insurance companies to get this line of business from Steward.

Knowing that there is currently an intense negotiation going on between Partners and Blue Cross Blue Shield of Massachusetts, I am putting my money on Option #1. It would take an absolute reduction in payments to the PHS hospitals to make those hospitals competitive with the other tertiary centers. As this story notes, PHS may be willing to slow down the future rate of increase of its reimbursements, but I'd be hard-pressed to believe that it is willing to reduce its current payments to a level below that received by its competitors. This is not a good time to send a signal to insurers that the current premium payments received by the two flagship hospitals are subject to that degree of haggling.

Friday, September 16, 2011

Remembering, as Shaw said, that we are "two peoples separated by a common language," I am nonetheless left aghast by some of the comments from British medical folks in response to a recent post by Anne Marie Cunningham on her blog, entitled "Social media, black humour, and professionals." Anne Marie is a GP and Clinical Lecturer in Cardiff University, Wales, UK, with a specific interest in improving the quality of medical education.

I'll excerpt the pertinent phrases from this post:

I came across a discussion between several male doctors on Twitter. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were "labia ward" and "birthing sheds" to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious.

I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as "madwives" . . .

I did feel the need to check with others how they felt about this exchange so I sent them a link to the collated tweets by private message. I wanted to find out if my own shock and revulsion was typical and also to gain some advice on what to do about this.

My account of this episode, so far, has been very personal. But I also want to place this story in a wider context within the medical education literature on professionalism and black humour. Is the use of derogatory humour or slang by medical professionals inappropriate? Berk thinks that: "Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion."

I want to raise this topic here -- in this public space -- so that I can think about how I respond to it in the future when I "overhear" it. The next time I may choose to ignore it. Despite Wear's suggestion that incidents like this provide "teachable moments", and should be challenged, the spaces of social media are much more exposed than a hospital corridor.

The comments on the blog reflected a variety of points of view, generally said in a thoughtful manner, but then the conversation spread over to Facebook, to this page. It was here that things picked up and revealed, in my mind, a mindset among some that was extremely upsetting. In addition to the personal attacks on the author, they indicate some underlying attitudes that make me squirm. Here are some samples. Sorry, expletives are not deleted:

The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you're offended, fuck off and don't follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I've heard...

Agree, she sounds like the most naive child like GP ever- most of us do have sense of humour I promise. Those that don't obviously do shit like "research social media"...

For those who have never heard/used this "dark" humour to which the article refers, every profession/trade/workplace make jokes about the work they do. Work is work, not all of it can be enjoyed, it is very normal to make light of things. This is especially true of the high stress environments mentioned in the article.

This sort of humourless blog is the reason that medical students are overfilled with touchy feely bullshit. The time spent doing this detracts from learning skills which might actually be useful on the shop floor such as clinical skills.

It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.

Oh and one more thing- my job is to provide the best clinical care I can to EVERY SINGLE patient that I meet. Not to act like a mewing prat. I'd rather be treated by someone who is a dick and gets it right than someone who is lovely but fucks it up. As one consultant once said "my house officers know everything there is to know about bereavement... except how to prevent it." Unless I'm parading a patient through the hospital corridors whilst they're mid shit on a commode I think most acts of indescretion are neither here nor there as long as I'm not deliberately killing people and, you know, trying to make them better and stuff...

Fortunately, we also see several examples of mature insight and thoughtful behavior:

I take offence being referred to as "insincere, narcissistic odious little fucker." If you read your MPS/MDS bulletins you will discover it people with your attitude to medical practice who are more likely to be sued for clinical troubles because you are too cocky to ever think you might be wrong.

Isn't the issue more to do with the use of public social media rather than the sense of humour? Medical acronyms exist both cos they're funny and to conceal information a layperson might take offence to, like flk or ttfo. I don't think the terms here would have offended anyone but the point is that Twitter isn't private and can be "overheard" by people who could take offence. Use acronyms or use closed social media. The whole world doesn't need to see what's essentially a conversation between a particular group with its own frames of reference.

From a patient's viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.

Some of you need to really take a long look at the dehumanising nature of your jobs and try to rise above it. Anne Marie Cunningham makes some valuable observations in her blog. As a former surgery SpR, lymphoma survivor, cabbage patch survivor on 2 occasions some of you make comments that make me very concerned for your emotional well being. Social media makes the world a smaller place. Sometimes you should refrain from writing down your thoughts in public places like to FB and Twitter. If nothing else, making derogatory remarks about people you are supposed to care about may in time blunt your ability to make compassionate and "patient-centred" decisions. Please guard against this.

This has issue has nothing to do with whatever subjectively constitutes "humour" in our personal opinion. It has everything to do with professionalism. No-one expects healthcare professionals to live on a Higher Plane. However, every hopes that the healthcare professionals that they work with will extend them the courtesy of treating them with respect. That includes not talking about them, in any context, at any time, in terms that they would not use if they were in the same room. So: guess which of the participants in this thread I'd like to co-create my healthcare, and share in my healthcare decision making?

Well said. Derogatory comments about people in your care, in a public forum, tell us lots about you , as do the self serving defensive "lalalalala I can't hear you I never do anything wrong" responses with ears covered.

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Here's a wonderful animation from Gregory Warner and Adam Cole presented by Marketplace on American Public Media. It explains one aspect of the medical arms race, although it focuses on local politicians as opposed to local doctors and hospitals.

Ironically and tragically, in light of the blog post below, current Medicare pricing stimulates this arms race. Recall, for example, my post about proton beam machines.

If you can't see the video, click here. (Thanks to Pamela Johnson for the heads up!)

Wednesday, September 14, 2011

The discussions in Washington, DC, about the future of Medicare and Medicaid have gone totally haywire. Check out this story in the New York Times.

We'll start with the lede:

As Congress opens a politically charged exploration of ways to pare the deficit, President Obama is expected to seek hundreds of billions of dollars in savings in Medicare and Medicaid, delighting Republicans and dismaying many Democrats who fear that his proposals will become a starting point for bigger cuts in the popular health programs.

Is this some odd way of the President delivering on his promises relative to his health care reform legislation? Remember, he said he was hoping for three things: (1) a reduction in health care costs; (2) an increase in access for people currently uninsured or under-insured; and (3) maintaining choice for people in their selection of doctors and hospitals. But, as I noted at the time:

On the cost front, the president for now seems to be confusing underlying costs with how much the government chooses to pay. . . . Reductions in appropriations might reduce costs to the federal government, but they do not reduce the underlying costs of care.

Well, maybe they intend to just cut the rates to doctors. After all, each year, just before an automatically scheduled rate reduction occurs, Congress votes to defer it. But this year for sure. Right.

Or maybe they will change the eligibility age for Medicare. From the Times:

In negotiations with Congressional Republicans in July, Mr. Obama went further. He indicated that he was willing to consider a gradual increase in the age of eligibility for Medicare . . .

Gee, we've come a long way from proposals that might have decreased the age of eligibility.

. . . and cuts in federal payments to states for Medicaid.

The head of the New York Hospital Association explains:

Further cuts in the growth of Medicare and Medicaid would not only impair access to care, but also lead to job loss in the health care industry, directly contravening the president’s goal of job creation.

I have made this point, too:

With 50% of American hospitals operating at a deficit right now, it is hard to imagine how a reduction in federal payments . . . deals with the cost problem.

It isn't often that I hope for gridlock in Washington, DC, but these folks seem so confused about what's up that paralysis might be just what the doctor ordered.